**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family and staff interviews, and review of policy titled ''Abuse Neglect and Exploitation policy'', the facility failed to maintain an environment free from verbal, sexual, and/or physical abuse for four residents (R) R#11, R#12, R#18, and R#28) of 31 sampled residents. The facility failed to ensure the residents were protected after allegations of abuse by suspending alleged perpetrators of abuse during each investigation of alleged abuse and failed to thoroughly investigate and report potential allegations of abuse. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the facility's ''Abuse Neglect and Exploitation policy'' dated 12/2017 indicated each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind . Resident will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, family members, friends or others. Bullet III. Prevention of Abuse, Neglect and Exploitation: Provide education on what constitutes abuse, neglect, and misappropriation of property. Take appropriate action to allegations or questions of abuse by residents, family members, employees, or visitors . Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. Bullet IV. Identification of Abuse, Neglect and Exploitation: The facility will consider factors indicating possible abuse, neglect and/or exploitation of residents including, but not limited to, the following possible indicators: Resident, staff or family report of abuse. Verbal abuse of a resident overheard. Physical abuse of a resident observed. 1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. The resident was discharged from the facility on 3/11/2023. The resident's admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment. Review of document titled Grievance Log dated 9/1/2022 through 4/26/2023 revealed a grievance entered on behalf of R#11 on 1/9/2023, by the resident's family member and the nature of the grievance indicated care. The log entry indicated the outcome was Reportable and the resolution date of the grievance indicated 1/17/2023 (more than a week after the grievance was initially reported). Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date (eight days after the initial report). Review of the ''Incident Follow-Up Investigation Report'' dated 1/17/2023 related to R#11's report of care concerns was reviewed and indicated Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. R#11 also alleged CNA BB and CNA CC left her lying in her own feces. According to the investigation report, the SW never reported the allegation of abuse to the Administration. Administration was not made aware of R#11's allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later) during a Circle of Care/Care Coordination Meeting. The investigation did not include interviews with residents related to potential verbal abuse and rough care by staff members, rather six residents were interviewed by the SW regarding the amount of time it took for staff to answer call lights. The investigation also did not include interviews with any other staff members other than the two CNAs about whom the allegations were made. CNA BB and CNA CC were not put on administrative leave after the first allegation of abuse on 1/9/2023 or during the investigation after a second report of abuse on 1/17/2023. Both CNAs continued to work in the facility with R#11 and other residents after the initial allegation of abuse. A physical assessment of the resident was not completed of R#11 after the allegation of abuse to ensure no injuries were obtained. The investigation conclusion revealed Abuse not verified. Both staff members were still working regularly at the facility in direct contact with residents through the survey exit date of 5/3/2023. Interview on 4/24/2023 at 12:30 p.m., R#11's RP confirmed report of an allegation of physical abuse/rough treatment by two CNAs was made to the facility social worker on 1/9/2023 and then again to the DON on 1/17/2023. Interview on 4/28/2023 at 5:45 p.m. with CNA CC, verified she was still working consistently in the facility as a CNA and indicated she did not recall R#11. She stated she did not remember ever being put on administrative leave related to any allegation of abuse. CNA BB was unavailable for interview during the survey. Interview on 4/27/2023 at 2:15 p.m., the Social Services Director (SSD) confirmed the Grievance related to R#11's allegation of physical and verbal abuse had not been reported to the facility's Administration as it should have. She stated the grievance should have been immediately referred to the Abuse Coordinator/Administrator on 1/9/2023 when the allegation was initially reported. 2. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses including gastrointestinal hemorrhage and anemia. The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Review of a ''Progress Notes,'' dated 4/9/2023 at 7:31 p.m. revealed the CNA reported to the writer that resident reported to her someone had come to her room and took his penis and rubbed it against her vagina. The writer accompanied by the fllor [sic] nurse went to the resident's room. Resident A/O [alert and oriented] x 2 narrated +- what the CNA had reported to the writer. With the help of the floor nurse the resident's generterial [sic] area was assessed. Noted was redness to inner thighs. Resident was also able to show where the rubbig [sic] was by touching the top of her vagina. The note indicated the facility's Abuse Coordinator'' (Administrator), the police, and the resident's family had been notified of the allegation. Review of the Incident Report Form, dated 4/9/2023, indicated an allegation of sexual abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, ''Resident informed staff that a man sexually abuse [sic] her, however she could not recall the date and time of the incident.'' Review of the Incident Follow-Up Investigation Report dated 4/9/2023 related to the resident's allegation of sexual abuse was reviewed and indicated Initial Report: Staff to Resident Sexual Abuse. The report indicated R#12 alleged sexual abuse by a staff member to an unidentified CNA on 4/9/2023 at approximately 7:30 p.m. The CNA immediately reported the allegation to the charge nurse. The resident reported that a male tech came into her room, took his penis, and rubbed it against her vagina. The investigation report indicated the resident was noted to have redness to her inner thighs and was able to point out the area that was being rubbed by pointing to the top of her vagina. The report indicated the resident was sent to the hospital after the report of sexual abuse on the evening of 4/9/2023 and sexual abuse could not be determined by the staff at the Emergency Department. Review of the investigation report revealed the facility did not attempt to identify the potential perpetrator of the abuse or conduct interviews with staff and residents to attempt to determine if the abuse had occurred. The investigation conclusion indicated unsubstantiated. Review of the Nursing Schedules, dated 4/7/2023 through 4/9/2023 revealed four male staff members had been working in direct contact with residents, including R#12 during the allegation timeframe. None of the four staff members were put on administrative leave during the investigation to ensure the residents' protection. All four of the identified staff members were still working consistently in the facility and in direct contact with residents as of the survey exit date of 5/3/2023. R#12 was unavailable for interview due to the resident being hospitalized for part of the survey timeframe and was too ill to interview/asleep during the remaining timeframe. Interview on 4/27/2023 at 10:25 a.m., the Administrator confirmed there were multiple male staff members who worked during the time frame of R#12's allegation. 3. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy. The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 8, which indicated moderate cognitive impairment. Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD. Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Both staff members confirmed the allegation of abuse by CNA DD. Both staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the investigation report, the allegation of potential abuse was not reported to the facility's Abuse Coordinator until the following morning. CNA DD was not put on administrative leave after the allegation of abuse, and instead remained in the facility for the remaining seven hours of her shift while working in direct contact with residents. According to the report, no additional staff interviews were conducted, and no resident interviews were conducted related to the allegation to determine if the abuse occurred. According to the records, R#28 was not physically assessed to determine if he had been injured during the incident. The investigation conclusion indicated: Unverified, even though reports of verbal abuse by CNA DD to R#28 were verified per interview with staff members present during the incident. Review of the Nursing Schedule for 12/21/2022 revealed CNA DD remained in the facility for the remainder of her shift on 12/21/2022. In addition, the schedule verified CNA DD was still working consistently in the facility as of the survey exit date of 5/3/2023. R#28 was unable to be interviewed related to the allegation due to his poor cognition. Interview on 4/29/2023 at 10:23 a.m. with CNA DD, indicated she was familiar with R#28 and stated she remembered the incident from 12/21/2022. She stated, All I know is I cleaned him [R#28] up and he didn't want to get clean. I cleaned him up and when I finished, I put the bed to the lowest [position] and he pushed himself to the ground. CNA DD confirmed she was not put on administrative leave on the night of the alleged abuse. She stated she remained in the facility working with residents until the end of her shift the next morning. CNA DD stated she was placed on administrative leave the next day after the Administrator arrived at work. She stated after the investigation was done, she was asked to return to work. Interview on 4/2720/23 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated abuse was to be reported to himself immediately after an allegation and stated any facility staff member could report abuse. He stated after abuse allegations had been reported to him, it was his responsibility to investigate the allegation. The Administrator confirmed his expectation was witness statements would be obtained and the police, the family, the physician, and the local Ombudsman be called. He stated the alleged perpetrator should be suspended pending the outcome of the investigation. The DON confirmed the allegation of potential abuse was not reported timely for R#11 and stated she did not believe any of the above investigations were thorough. The Administrator stated, We should have interviewed residents about staff treatment and other staff as well (related to the above allegations of potential abuse). Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC) stated his expectation was any allegation of abuse was to be reported to a supervisor immediately and the supervisor was to then immediately call the Abuse Coordinator. He stated allegations of abuse were expected to be thoroughly investigated and residents were to be protected while the investigation was conducted. 4. Review of the policy titled Accidents and Supervision, Investigation, and Reporting, revised 9/2022, indicated the facility shall provide the residents an environment free of accident hazards and each resident receives adequate supervision and assistive devices to prevent accidents. All accidents or incidents must be reported and recorded. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia. The resident's MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally. Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care. The care plan indicated R18 had a diagnosis of atrial fibrillation and required the administration of blood thinners. Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's RP refused stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport. Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple. Review of a document titled Risk Management indicated R#18 had an injury of unknown cause on 4/12/2023 at 3:00 p.m. The document recorded family members at bedside and requested an immediate call to 911 for EMS (Emergency Medical Services) to remove the resident from facility due to their concerns of care. Resident states that her left great toe and foot has pain and there is a small bruise on top of left great toe, and small bruise to left ankle, and a yellow discoloration to left temple. Scattered petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to right shin. Head to [sic] assessment from wound care nurse completed. 911 called to transport patient to acute hospital per family request. Administrator aware and submitting reportable and called Ombudsman. The DON notified MD and RP and [family member] at bedside onsite at facility and packed up her belongings. DON answered all question for family. Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the facility offered to obtain an x-ray, but the family declined. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. There was no documentation of steps taken by the facility to prevent further incidents. The conclusion of the investigation on 4/12/2023 recorded, . The conclusion of this investigation is inconclusive. During the interview with DON and others, the resident stated that she wasn't experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action . Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI (Quality Assurance and Performance Improvement) in facility up-coming QAPI. Interview on 4/26/2023 at 4:29 p.m., the Wound Care Nurse (WCN) stated R#18 was not able to turn and reposition herself, had limited range of motion to her upper extremities, and required full assistance with bilateral lower extremity movement. Interview on 4/27/2023 at 7:00 p.m., the CNC stated R#18's injuries noted on 4/12/2023 were not reported because nothing happened. Interview on 4/28/2023 at 9:40 a.m., the Visiting Administrator (VA) EE confirmed the facility did not do an investigation on 4/12/2023 related to R#18's injuries and no witness statements or investigation documentation were available. Interview on 4/28/2023 at 10:37 a.m., the WCN confirmed that she performed a full body skin assessment on R#18 with the family at the bedside. WCN stated R#18's family member reported bruising to left upper foot and further skin assessment revealed yellow discoloration to the temple, purple/blue discoloration to bilateral upper extremities, and petechiae to left lower extremity, and a small ulcer opening to the labia. Interview on 4/28/2023 at 10:58 a.m., the DON confirmed that on 4/12/2023, R#18's family was visiting in the resident's room and was upset, stating they wanted her moved out of the facility. The DON she was not aware of any bruising to R#18's body but was aware that the resident was complaining of foot pain. The DON stated the WCN performed a full body skin assessment which revealed discoloration to her foot, possible injury to the foot, and pain reported in one of her feet. Interview on 4/28/2023 at 2:55 p.m., the Administrator/Abuse Coordinator stated that he reported the injury on 4/12/2023 but did not submit a five-day follow-up. The Administrator did not provide a reason the five-day follow-up report was not submitted. Interview on 4/28/2023 at 4:24 p.m., the Infection Preventionist (IP) confirmed that on 4/12/2023 she was employed as the ADON and was asked to speak with R#18's family at the bedside. The IP stated she was made aware of a dark purple discoloration to R#18's left great toe, along with purple discoloration to the left ankle, and yellow discoloration to the left temple/forehead area. The ADON confirmed that staff working with R#18 should have reported any bruising immediately but did not. The IP confirmed it was the family member who brought the bruising to the attention of the facility. Interviews with 11 staff members throughout the facility on 4/27/2023 between 12:00 p.m. and 12:30 p.m. indicated nine of 11 staff members were agency staff working in the facility and three of 11 reported they had not received abuse training from the facility. One agency CNA staff member indicated she had not received abuse training from either her agency or the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family and staff interviews, and review of the policy titled Abuse Neglect and Exploitation policy and Accidents and Supervision, Investigation, and Reporting, the facility failed to ensure the immediate reporting of verbal, sexual, and/or physical abuse for three of 31 sampled residents (R) (R#11, R#18, and R#28). Specifically, the facility failed to ensure allegations of physical and verbal abuse for R#11 and R#28 were reported to the Abuse Coordinator, and an allegation of physical abuse was reported timely to the State Survey Agency (SSA) for R#18. The facility's systemic failure to ensure the reporting of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the policy titled Abuse Neglect and Exploitation policy, dated 12/2017 indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Reporting/Documentation Requirements: When abuse, neglect or exploitation is suspected: immediately report all alleged violations to the Administrator/Designee, state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) within specified timeframes. 1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. Resident #11 is a new admission and entry tracking Minimum Data Set (MDS) dated [DATE] is only MDS available, therefore, no data available at this time. R#11's Brief Interview for Mental Status (BIMS) score, dated 1/6/2023 and found in the electronic medical record (EMR) under the MDS tab, was 14, indicating the resident was cognitively intact. Review of document titled Grievance Log dated 9/1/2022 through 4/26/2023 revealed a grievance entered on behalf of R#11 on 1/9/2023, by the resident's family member and the nature of the grievance indicated care. The log entry indicated the outcome was Reportable and the resolution date of the grievance indicated 1/17/2023, eight days after the grievance was initially reported. Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date (eight days after the initial report). Review of the Incident Follow-Up Investigation Report related to the resident's report of care concerns dated 1/17/2023 indicated, Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. She alleged CNA BB and CNA CC left her lying in her own feces. According to the investigation report, the SW never reported the allegation of abuse to the Administration. Administration was not made aware of these allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later). Because the allegation of abuse was not timely reported to the Administration, CNA BB and CNA CC were not put on administrative leave and continued to work in the facility with R#11 and other residents for eight days after the initial allegation of abuse. Review of the Nursing Schedules, dated 1/9/2023 through 1/17/2023 revealed CNA BB and CNA CC remained at work in direct contact with residents, including R#11. Interview on 4/24/2023 at 12:30 p.m., responsible party (RP) for R#11, confirmed report of an allegation of physical abuse/rough treatment by two CNAs was made to the facility SW on 1/9/2023 and then again to the DON on 1/17/2023. Interview on 4/28/2023 at 5:45 p.m., CNA CC, she verified she was still working consistently in the facility as a CNA and indicated she did not recall R#11. CNA CC stated she did not remember ever being put on administrative leave related to any allegation of abuse. Interview on 4/27/2023 at 2:15 p.m., the Social Services Director (SSD) confirmed the Grievance related to R#11's allegation of physical and verbal abuse had not been reported to the facility's Administration as it should have. She stated the grievance should have been immediately referred to the Abuse Coordinator/Administrator on 1/9/2023 when the allegation was initially reported. 2. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy. The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD. Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help, and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging, he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Two staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the investigation report, the allegation of potential abuse was not reported to the facility's Abuse Coordinator until the following morning. Because the alleged abuse was not timely reported to the Administrator/Abuse Coordinator until the morning of 12/22/22, CNA DD was not put on administrative leave after the allegation of abuse, and instead remained in the facility for the remaining seven hours of her shift while working in direct contact with residents. Review of the Nursing Schedules, dated 12/21/2022 revealed CNA DD remained in the facility for the remainder of her shift on 12/21/2022, in direct contact with residents, including R#28. Interview on 4/29/2023 at 10:23 a.m. with CNA DD, confirmed she was not put on administrative leave on the night of the alleged abuse. She stated she remained in the facility working with residents until the end of her shift the next morning. She stated she was put on administrative leave the next day after the Administrator arrived at work. Interview on 4/27/2023 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated abuse was to be reported to himself immediately after an allegation and stated any facility staff member could report abuse. He stated after abuse allegations had been reported to him, it was his responsibility to investigate the allegation. Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC), serving as Interim Director of Nursing (DON), stated his expectation was any allegation of abuse was to be reported to a supervisor immediately and the supervisor was to then immediately call the Abuse Coordinator. 3. Review of the policy titled Accidents and Supervision, Investigation, and Reporting, revised September 2022, revealed all accidents or incidents must be reported and recorded. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia. The resident's annual MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally. Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care. Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. The DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's two daughters refused, stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport. Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae (pinpoint, round spots that appear on the skin as a result of bleeding) to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple. Review of a document titled Risk Management indicated R#18 was noted to have an injury of unknown cause on 4/12/2023 at 3:00 p.m. The document recorded family members at bedside and requested an immediate call to 911 for EMS (Emergency Medical Services) to remove the resident from facility due to their concerns of care. Resident states that her left great toe and foot has pain and there is a small bruise on top of left great toe, and small bruise to left ankle, and a yellow discoloration to left temple. Scattered petechiae to right shin. Head to [sic] assessment from wound care nurse completed. 911 called to transport the patient to acute hospital per family request. Administrator aware and submitting reportable and called Ombudsman. The DON notified MD and RP and sister at bedside. Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. The incident report's conclusion portion indicated the investigation is inconclusive. During the interview with DON and others, the resident stated that she wasn't experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action is Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI (Quality Assurance and Performance Improvement) in facility up-coming QAPI. Interview on 4/27/2023 at 7:00 p.m., the CNC stated R#18's injuries noted on 4/12/2023 were not reported because nothing happened. Interview on 4/28/2023 at 10:37 a.m., the WCN confirmed that she performed a full body skin assessment on R#18 after the family had reported bruising to her left upper foot. The WCN reported the skin assessment revealed yellow discoloration to the temple, purple/blue discoloration to bilateral upper extremities, petechiae to left lower extremity, and a small ulcer opening to the labia. Interview on 4/28/2023 at 10:58 a.m., the DON confirmed that on 4/12/2023, R#18's family reported she had bruising of which she was unaware. The DON stated she was aware of R#18's complaints of foot pain. The DON stated the WCN performed a full body skin assessment and that is when she became aware of the bruising on R18's body. which revealed discoloration to her foot, possible injury to the foot, and pain reported in one of her feet. Interview on 4/28/2023 at 2:55 p.m., the Administrator/Abuse Coordinator stated that he reported the injury on 4/12/2023 but confirmed he did not submit a five-day follow-up. The Administrator did not provide a reason the five-day follow-up report was not submitted. Interview on 4/28/2023 at 4:24 p.m., the Infection Preventionist (IP) confirmed that staff working with R#18 did not report the bruising immediately as they should have reported. The IP confirmed it was the family member who brought the bruising to the attention of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family and staff interviews, and review of the policy titled Abuse Neglect and Exploitation policy, the facility failed to ensure allegations of verbal, sexual, and/or physical abuse were thoroughly investigated for four of 31 sampled residents (R) (R#11, R#12, R#18, and R#28). Specifically, resident and staff interviews were not conducted during investigations into the allegations to determine if abuse occurred, and the facility failed to identify potential perpetrators of abuse. The facility's systemic failure to ensure the thorough investigation of abuse allegations created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the policy titled Abuse Neglect and Exploitation policy dated 12/2017 indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Residents will not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants, volunteer staff, family members, friends, or others. Investigation of abuse, neglect, and exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: Identifying staff responsible for the investigation; Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering or destroying evidence); Ensure resident safety is not jeopardized. Physically assess resident; Investigating different types of alleged violations; Identifying an interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, ensure confidentiality; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation; Continue investigation to determine if other residents may be at risk for similar occurrences. If similar residents are at risk, appropriate measures/changes will be implemented. 1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. The resident was discharged from the facility on 1/11/2023. Resident #11 is a new admission and entry tracking Minimum Data Set (MDS) dated [DATE] is only MDS available, therefore, no data available at this time. R#11's Brief Interview for Mental Status (BIMS) score, dated 1/6/2023 and found in the electronic medical record (EMR) under the MDS tab, was 14, indicating the resident was cognitively intact. Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date. Review of the Incident Follow-Up Investigation Report related to the resident's report of care concerns dated 1/17/2023 indicated, Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. She alleged CNA BB and CNA CC left her lying in her own feces. Administration was not made aware of these allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later). The investigation did not include interviews with residents related to potential verbal abuse and rough care by staff members, rather six residents were interviewed by the SW regarding the amount of time it took for staff to answer call lights. The investigation did not include interviews with other staff members, other than the two CNAs about whom the allegations were made. In addition, a physical assessment was not completed of R#11 after the allegation of potential abuse to ensure no injuries were obtained. 2. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses including gastrointestinal hemorrhage and anemia. R#12's BIMS score, dated 3/27/2023, and found in the EMR under the MDS tab, was 13, indicating the resident was cognitively intact. Review of a ''Progress Notes,'' dated 4/9/2023 at 7:31 p.m. revealed CNA reported to the writer that resident reported to her someone had come to her room and took his penis and rubbed it against her vagina. Review of the Incident Report Form, dated 4/9/2023, indicated an allegation of sexual abuse was entered into the facility's incident tracking system on that date for R#12. The details indicated, ''Resident informed staff that a man sexually abuse [sic] her, however she could not recall the date and time of the incident.'' Review of the Incident Follow-Up Investigation Report dated 4/9/2023 related to the resident's allegation of sexual abuse was reviewed and indicated Initial Report: Staff to Resident Sexual Abuse. The report indicated R#12 alleged sexual abuse by a staff member to an unidentified CNA on 4/9/2023 at approximately 7:30 p.m. Review of the investigation report revealed the facility did not attempt to identify the potential perpetrator of the abuse or conduct interviews with staff and residents to attempt to determine if the abuse had occurred. The investigation conclusion indicated unsubstantiated. Review of the Nursing Schedules, dated 4/7/2023 through 4/9/2023 revealed four male staff members had been working in direct contact with residents, including R#12 during the allegation timeframe. There was no investigation to specifically rule in or out if any of the four male staff members who were identified as working in direct contact with residents during the time frame of the allegation of sexual abuse. 3. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy. R#28's BIMS score, dated 2/2/2023, and found in the EMR under the MDS tab, was eight, indicating the resident was moderately cognitively impaired. Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD. Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help, and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging, he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Two staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the report, no additional staff interviews were conducted, and no resident interviews were conducted related to the allegation to determine if the abuse occurred. According to the records, R#28 was not physically assessed to determine if he had been injured during the incident. The investigation conclusion indicated: Unverified, even though reports of verbal abuse by CNA DD to R#28 were verified per interview with staff members present during the incident. Interview on 4/2720/23 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated after an abuse allegation had been reported to him, it was his responsibility to investigate the allegation. The Administrator confirmed his expectation was witness statements would be obtained, including additional residents and staff who might know of the potential abuse. The DON stated she did not believe any of the above investigations were thorough. The Administrator stated, We should have interviewed residents about staff treatment and other staff as well (related to the above allegations of potential abuse). Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC) stated his expectation was any allegation of abuse was expected to be thoroughly investigated and residents were to be protected while the investigation was conducted. 4. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia. The resident's MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally. Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care. Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. The DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's two daughters refused, stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport. Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae (pinpoint, round spots that appear on the skin as a result of bleeding) to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple. Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. There was no documentation of steps taken by the facility to prevent further incidents. Review of the Incident Follow-Up Investigation Report dated 4/28/2023 at 11:00 p.m. and signed by the Administrator indicated summary of interview(s) with other residents: at approximately 3:10 p.m., resident 30-A was asked if she had observed anyone mistreat [R#18] and responded no. At 3:15 p.m., resident 30-B was asked if they had observed anyone mistreating [R#18] and responded no. At 3:18 p.m., resident 31-A was asked if she had observed anyone mistreating [R#18] and responded that she was not aware. The Report recorded the direct-care staff assigned to R#18 on 4/12/2023 was asked if she had observed a bruise on R#18's left foot, and she stated she saw a little purple bruise on the foot but did not report it. The Report recorded the charge nurse assigned to R#18 on that day denied knowledge of R#18 being in pain. The conclusion section of the report indicated, . The conclusion of this investigation is inconclusive. During the interview with DON and others, the resident stated that she was not experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action . Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI [Quality Assurance and Performance Improvement] in facility up-coming QAPI. There was no documentation of the residents' interviews or whether the residents were asked any other questions related to abuse and neglect. There were no interviews with staff members or potential witnesses, other than the two assigned to the resident. The report was not completed until 04/28/23, after the surveyors had brought the incident to the attention of the Administrator.

Based on record review, interviews, and review of the policy titled Abuse Neglect and Exploitation, the facility failed to ensure administration provided oversight and monitoring related to the prevention, reporting and investigation of abuse. Four of 31 sampled residents (R) (R#11, R#12, R#18, and R#28) reported allegations of abuse and these allegations were not reported and/or investigated per facility policy. In addition, the Administration failed to ensure residents were appropriately protected from further potential abuse after the allegations. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the policy titled Abuse Neglect and Exploitation dated December 2017 indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Residents will not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants, volunteer staff, family members, friends or others. Bullet III. Prevention of Abuse, Neglect and Exploitation: Provide education on what constitutes abuse, neglect, and misappropriation of property. Take appropriate action to allegations or questions of abuse by residents, family members, employees, or visitors. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. Bullet IV. Identification of Abuse, Neglect and Exploitation. The facility will consider factors indicating possible abuse, neglect and/or exploitation of residents including, but not limited to, the following possible indicators: Resident, staff, or family report of abuse. Verbal abuse of a resident overheard. Physical abuse of a resident observed. Reporting/Documentation Requirements: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator/Designee, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specified time frames. Investigation of abuse, neglect, and exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include, identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence; ensure resident safety is not jeopardized. Physically assess resident; investigating different types of alleged violations; Identifying an interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, ensure confidentiality; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation; continue investigation to determine if other residents may be at risk for similar occurrences. If similar residents are at risk, appropriate measures/changes will be implemented. Review of the Administrator Job Description indicated the Basic Function: Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state, and local standards, guidelines and regulations as directed by corporate office and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Number 6. Ensure that patient/resident rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints are well established and maintained at all times. The Role of the Abuse Coordinator within the facility's undated Abuse Investigation and Reporting Policies, revealed the role of the Abuse Coordinator: 1. The facility administrator may take the role of the Abuse Coordinator in the facility. 2. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown origin is reported, the Administrator/Abuse Coordinator will assign the investigation to an appropriate individual. 3. The Abuse Coordinator shall provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 4. The Abuse Coordinator or designated staff shall keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator/Abuse Coordinator or designated staff (i.e., DON (Director of Nursing), Department Manager) shall suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 6. The Administrator/Abuse Coordinator shall ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. 7. The Administrator or designated staff shall inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Review of the Incident Follow-Up Investigation Report revealed on 1/9/2023, an allegation of physical and verbal abuse was reported for R#11 to the Social Worker (SW). The allegation was not reported to the Administration until 1/17/2023, by R#11's Responsible Party. After the allegation of physical abuse was reported to administration on 1/17/2023, the facility failed to ensure resident safety by suspending the potential perpetrator, failed to assess the resident for potential injury, and failed to thoroughly investigate the allegation of abuse (staff and resident interviews were not completed to attempt to identify whether abuse was occurring in the facility). Due to the staff member not reporting the abuse allegations timely, Certified Nursing Assistant (CNA) BB and CNA CC continued to work with residents. Review of the Incident Follow-up Investigation Report revealed on 4/9/2023, an allegation of sexual abuse was reported for R#12. The facility failed to ensure resident safety by suspending the potential perpetrators and failed to thoroughly investigate the allegation of abuse (staff and resident interviews were not completed to attempt to identify whether or not abuse was occurring in the facility). The facility failed to attempt to identify the staff member who perpetrated the abuse, hence allowing multiple potential perpetrators (male staff members) to continue to work with residents during the investigation. Review of the Facility Reported Incident revealed on 4/12/2023, an allegation of multiple injuries of unknown origin/physical abuse was reported for R#18. Facility staff failed to timely report the injuries to administration, the facility failed to thoroughly investigate the injuries of unknown origin (staff and resident interviews were not completed to attempt to identify whether abuse was occurring in the facility), and the facility did not perform a follow-up investigation (5-day) until 4/28/2023. Review of the Incident Follow-Up Investigation Report revealed on 12/21/2022, an allegation of physical and verbal abuse by CNA DD was made for R#28. The facility did not ensure resident safety by suspending the alleged perpetrator during the investigation (the alleged perpetrator remained at work for the remainder of her shift while working in direct contact with residents), R#28's allegation of abuse was not reported to facility Administration until the next morning (12/22/2022), an investigation into the allegation of physical/verbal abuse was not thorough (it failed to include interviews of staff and residents to determine whether the abuse occurred), and the resident was not physically assessed related to the allegation of physical/verbal abuse. In addition, the alleged abuse allegation was not substantiated despite reports from two staff members that the alleged perpetrator of the abuse loudly made the statement ''You should have offered him some food and watched how fast he got up'' in front of the resident before knocking the residents' cups off his overbed table and storming out of the room. Interview 4/27/2023 at 10:25 a.m., the Director of Nursing (DON) and the Administrator confirmed the Administrator acted as the facility's Abuse Coordinator. The Administrator confirmed the above staff members were not placed on suspension per policy, assessments were not completed of the residents per policy, and the investigations into the allegations of abuse were not thorough. Interview on 4/27/2023 at 1:05 p.m., the Administrator stated in response to the survey team's questions, you were right. I thought I was thorough but that is not what it is. [After talking with the surveyors] I realize staff should be suspended and were not suspended. Interview on 4/29/2023 at 12:30 p.m., the DON stated she was aware the abuse investigations were not thorough. She stated the Administrator was the facility's abuse coordinator and his involvement with abuse investigations was not what it should be. Cross-reference F600, F609, and F610.